Princeton Community Hospital Defined Contribution 403(b) Plan

Transcription

1 Separation from Employment Withdrawal Request 403(b) Plan Princeton Community Hospital Defined Contribution 403(b) Plan When would I use this form? When I am requesting a withdrawal and I am no longer employed by the employer/company sponsoring this Plan. Additional Information For purposes of this form, the terminology 'Separation' is the same as 'Severance', 'Employment' is the same as 'Service' and 'Withdrawal' is the same as 'Distribution'. By logging into my account on the website at I may confirm the address that is on file and track the status of this withdrawal request. For questions regarding this form, refer to the attached Participant Withdrawal Guide ("Guide"), visit the website at participant or contact Service Provider at Return Instructions for this form are in Section I. Use black or blue ink when completing this form. A What is my personal information? Account extension, if applicable, identifies funds transferred to a beneficiary due to participant's death, alternate payee due to divorce or a participant with multiple accounts. Account Extension - - Social Security Number or Taxpayer Identification Number (Must provide all 9 digits) Last Name First Name M.I. Address - By providing an address above, I am consenting to receive s related to this request. Select One: U.S. Citizen Non-Resident Alien or Other U.S. Resident Alien B What is my reason for this withdrawal? Must select only one reason. Country of Residence (Required - See Guide for IRS Form W-8BEN information.) / / Date of Birth (mm/dd/yyyy) Married Unmarried ( ) Daytime Phone Number ( ) Alternate Phone Number Separation from Employment or Retirement Date (Required): / / (mm/dd/yyyy) I have Separated from Employment I have Retired C What type of withdrawal and how much am I requesting? 100% withdrawal will be the Maximum Amount Available Required Minimum Distribution (Age 70½ or older) Effective Date: (Required if requesting a future dated withdrawal within the next 180 days. If left blank and request is in good order, withdrawal will be processed as soon as administratively feasible.) Do I want my funds associated with Great-West SecureFoundation Guaranteed Lifetime Withdrawal Benefit ("GLWB") to be included with this withdrawal request? Yes No (See the Guide for additional information) If I elect to include these funds with all other assets on this request, I may reduce my Benefit Base and may eliminate the associated guaranteed income benefit. The funds associated with GLWB are: Great-West SecureFoundation Balanced G Payable to Me as a One-time Withdrawal Amount % or $ Contribution Source: If I am electing this option for my Required Minimum Distribution, I must enter a dollar amount. Percentages are unavailable. Net Amount (The amount I will receive after applicable income taxes and fees are withheld.) Gross Amount (The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.) 100% Withdrawal With A Portion Payable to Me and the Remaining Balance as a Direct Rollover Payable to Me Amount % or $ (If the Payable to Me Amount is to fulfill my Required Minimum Distribution, I must enter a dollar amount. Percentages are unavailable.) Net Amount (The amount I will receive after applicable income taxes and fees are withheld.) Gross Amount (The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.) Page 1 of 16

2 Last Name First Name M.I. Social Security Number Number C What type of withdrawal and how much am I requesting? 100% withdrawal will be the Maximum Amount Available Direct Rollover Amount 100 % of the remaining balance Empower Retirement IRA (To avoid any processing delays, contact the Retirement Solutions Center at to open an account by phone OR complete an Empower Retirement IRA Application at $ minimum vested balance required.) Traditional IRA Roth IRA (Taxable event - Subject to ordinary income taxes and withholding) Empower Brokerage IRA (Enter the Empower Brokerage IRA account number. To open a brokerage IRA account, contact the Brokerage Retirement Specialists at ; $ minimum vested balance required.) Traditional IRA Account Number (Required) Roth IRA Account Number (Required) (Taxable event - Subject to ordinary income taxes and withholding) At Another Retirement Provider Eligible Retirement Plan: 401(a) 401(k) 403(b) Governmental 457(b) Traditional IRA Roth IRA (Taxable event - Subject to ordinary income taxes) Rollover to an Empower Retirement IRA as a One-time Withdrawal (To avoid any processing delays, contact the Retirement Solutions Center at to open an account by phone OR complete an Empower Retirement IRA Application at $ minimum vested balance required.) Traditional IRA Roth IRA Required Minimum Distribution Amount % or $ Amount % or $ (Taxable event - Subject to ordinary income taxes) If I am requesting a 100% Withdrawal as a Direct Rollover and I am age 70½ or older by the end of this year, I am no longer working for the employer/company sponsoring this Plan, and if I have not yet satisfied my required minimum distribution for this year, my required amount must be distributed to me prior to processing this rollover request. Required Minimum Distribution Amount $ Also complete Required Minimum Distribution portion of the How will my income taxes be withheld? section. Rollover to an Empower Brokerage IRA as a One-time Withdrawal (Enter the Empower Brokerage IRA account number. To open a brokerage IRA account, contact the Brokerage Retirement Specialists at ; $ minimum vested balance required.) Traditional IRA Amount % or $ Account Number (Required) Roth IRA Amount % or $ Account Number (Required) (Taxable event - Subject to ordinary income taxes) Required Minimum Distribution If I am requesting a 100% Withdrawal as a Direct Rollover and I am age 70½ or older by the end of this year, I am no longer working for the employer/company sponsoring this Plan, and if I have not yet satisfied my required minimum distribution for this year, my required amount must be distributed to me prior to processing this rollover request. Required Minimum Distribution Amount $ Also complete Required Minimum Distribution portion of the How will my income taxes be withheld? section. Rollover to an IRA at Another Retirement Provider or an Eligible Retirement Plan as a One-time Withdrawal Eligible Retirement Plan: 401(a) 401(k) 403(b) Governmental 457(b) Amount % or $ Traditional IRA Roth IRA Required Minimum Distribution Amount % or $ Amount % or $ (Taxable event - Subject to ordinary income taxes) If I am requesting a 100% Withdrawal as a Direct Rollover and I am age 70½ or older by the end of this year, I am no longer working for the employer/company sponsoring this Plan, and if I have not yet satisfied my required minimum distribution for this year, my required amount must be distributed to me prior to processing this rollover request. Required Minimum Distribution Amount $ Also complete Required Minimum Distribution portion of the How will my income taxes be withheld? section. Page 2 of 16

3 Last Name First Name M.I. Social Security Number Number C What type of withdrawal and how much am I requesting? 100% withdrawal will be the Maximum Amount Available Periodic Installment Payments (Complete the information below.) I am requesting to establish a new Periodic Installment Payment. I am making a change to an existing Periodic Installment Payment. I am requesting a one-time withdrawal payable to me in the amount of $ or % and at the same time I am requesting this Periodic Installment Payment. Net Amount (The amount I will receive after applicable income taxes and fees are withheld.) Gross Amount (The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.) First Payment Processing Date: / / (1st - 28th only) Frequency - Select One: Monthly Quarterly Semi-Annually Annually Payment Type - Select One: Amount Certain (Gross Amount Only) $ Period Certain (Specific Number of Years) Interest Only Payments, Converted to Required Minimum Distribution at age 70½ (Must have at least one fixed investment option and attach copy of Birth Certificate or Driver s License) Fixed Annuity Purchase (Complete information below and see Guide for additional information about the available options.) I need to attach the IRS Form W-4P and, if applicable, state income tax withholding form. Full Partial $ Purchase Date: / / First Payment Processing Date: / / Frequency - Select One Monthly Quarterly Semi-Annually Annually Payment Type - Select One Income of an Amount Certain (Gross Amount Only) $ Income for a Period Certain (Number of Years) The following payment type options have monthly frequencies only. Fixed Life Annuity with Guaranteed Period (Attach copy of Birth Certificate or Driver s License) Select Guaranteed Period: 5 Years 10 Years 15 Years 20 Years Fixed Life Annuity - Life Only, No Death Benefit (Attach copy of Birth Certificate or Driver s License) Joint Life (Attach copy of Birth Certificate or Driver s License for both primary and joint annuitants) Joint Annuitants Name: Select Survivor Benefit: 50% 75% 100% Relationship: Select Guaranteed Period (Optional): 5 Years 10 Years 15 Years 20 Years D If I am requesting a Rollover, To whom do I want my withdrawal payable and where should it be sent? Do not complete if requesting Payable to Me, Rollover to Empower Retirement IRA, Empower Brokerage IRA or Fixed Annuity Purchase. Name of Trustee/Custodian/Provider - Required (To whom the check is made payable) Account Number Mailing Address Retirement Plan Name (if applicable) E How do I want my withdrawal delivered? Select One - Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order. City/State/Zip Code ( ) Phone Number If no option is selected, all transactions will be sent by United States Postal Service ("USPS") regular mail. If I would like to make a change to what I previously selected, I must cross-out and initial the change(s). If I do not initial all changes, all transactions will be sent by USPS regular mail. Check by USPS Regular Mail Estimated delivery time is 7-10 business days No additional charge Check by Express Delivery Estimated delivery time is 1-2 business days A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction. For example, if I elected to make a full withdrawal with a portion payable to me and the remainder rolled over to an eligible plan, there will be 2 different transactions and I may be charged up to a total of $50.00 for the Express delivery fees. Not available for Periodic Installment/Annuity Payments Available for delivery, Monday - Friday, with no signature required upon delivery If address is a P.O. Box, check will be sent by USPS Express mail and estimated delivery time is 2-3 business days. Page 3 of 16

4 Last Name First Name M.I. Social Security Number Number E How do I want my withdrawal delivered? Select One - Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order. Direct Deposit via Automated Clearing House ("ACH") Estimated delivery time is 2-3 business days A non-refundable charge of up to $15.00 will be deducted, in addition to any withdrawal fees, for each transaction. Not available for Direct Rollovers Available for Periodic Installment/Annuity Payments at no charge If I have requested a periodic installment payment and my first payment processing date does not allow for the 10 day pre-notification process, I understand that my first payment will be sent by check to my address on file. The name on my checking/savings account MUST match the name on file with Service Provider. Failure to provide mandatory supporting documentation will result in a significant delay in my request. Checking Account - MUST include a copy of a preprinted voided check for the receiving account. I may also attach a letter on financial institution letterhead, signed by a representative from the receiving institution, which includes my name, checking account number and ABA routing number. Savings Account - MUST include a letter on financial institution letterhead, signed by a representative from the receiving institution, which includes my name, savings account number and ABA routing number. An ACH request cannot be sent to a prepaid debit card, business account or other retirement plan. If the ACH information outlined above is missing, incomplete or inaccurate, this request may be rejected and my withdrawal may be delayed. By requesting my withdrawal via ACH deposit, I certify, represent and warrant that the account requested for an ACH deposit is established at a financial institution or a branch of a financial institution located within the United States and there are no standing orders to forward any portion of my ACH deposit to an account that exists at a financial institution or a branch of a financial institution in another country. I understand that it is my obligation to request a stop to this ACH deposit request if an order to transfer any portion of payments to a financial institution or a branch of a financial institution outside the United States will be implemented in the future. Service Provider reserves the right to reject the ACH request and deliver any payment via check in lieu of direct deposit. Wire Transfer Estimated delivery time is 1-2 business days A non-refundable charge of up to $40.00 will be deducted, in addition to any withdrawal fees, for each transaction. For example, if I elected to make a full withdrawal with a portion payable to me and the remainder rolled over to an eligible plan, there will be 2 different transactions and I may be charged up to a total of $80.00 for the Wire transfer delivery fees. Not available for Periodic Installment/Annuity Payments MUST include a letter on financial institution letterhead, signed by a representative from the receiving institution, which provides the wire transfer instructions. The letter must include the following wire transfer information: Bank Name, complete Bank Mailing Address, including City, State and Zip Code, Account Name, Account Number, ABA Routing Number and 'For Further Credit to' Name and Account Number. Additional fees may apply at the receiving financial institution. Service Provider is not responsible for inaccurate wire transfer instructions. F What are my Outstanding Loan options? If I have an existing loan, I must select one option. Treat my outstanding loan balance (principal and interest) as a taxable withdrawal. I would like to pay off my outstanding loan balance in full. To pay off my loan, I need to: 1. Visit the website at or call to obtain a payoff quote and, 2. Attach payment made payable to Great-West Financial (Consider submitting payment by certified check or bank money order) and, 3. Mail this form and the loan payoff check to one of the following addresses: Regular Mail: Great-West Financial PO Box Denver, CO OR Express Delivery (request a.m. delivery): US Bank East 40th Avenue Suite 100 Dept #0889 Denver, CO G How will my income taxes be withheld? Not applicable if requesting a Rollover, unless I need to satisfy my required minimum distribution. I should refer to and read the attached 402(f) Notice of Special Tax Rules on Distributions and the Guide, as well as information from the Department of Revenue for my state of residence. If applicable, I must attach IRS Form W-4P and/or my State Income Tax withholding form to make tax elections when required. In the event these forms are required for my withdrawal and not submitted, or in the event my withholding election(s) below are left blank or do not comply with the applicable Federal and State regulations, Service Provider will withhold taxes from this withdrawal in accordance with applicable Federal and State regulations. Page 4 of 16

5 Last Name First Name M.I. Social Security Number Number G How will my income taxes be withheld? Not applicable if requesting a Rollover, unless I need to satisfy my required minimum distribution. Federal Income Tax Federal Income Tax will be withheld based on the reason and type of withdrawal I have selected. I would like additional Federal Income Tax withholding (Optional): % or $ (This is in addition to any mandatory Federal Income Tax withheld based on the reason and type of withdrawal I have selected.) Required Minimum Distribution Only (Age 70½ or Older) 10% of my taxable distribution will be withheld for Federal Income Tax, unless I check the box below: Do not withhold 10% Federal Income Tax from my Required Minimum Distribution. I would like additional Federal Income Tax withholding (Optional): % or $ (This is in addition to any 10% Federal Income Tax withholding) State Income Tax State Income Tax withholding is mandatory in some states and will be withheld regardless of any election below. I would like additional State Income Tax withholding: % or $ (This is in addition to any mandatory State Income Tax withheld based on the reason and type of withdrawal.) Certain states allow an election for no State Income Tax withholding depending on the reason and type of withdrawal I have selected. For these states only, State Income Tax will be withheld unless I elect otherwise below. If the checkbox is not marked below, I choose to have State Income Tax withheld from my withdrawal. I would also like to have additional State Income Tax withholding: % or $ (This is in addition to any elective State Income Tax withheld based on the reason and type of withdrawal.) Do not withhold State Income Tax (if election is permitted and I have attached the proper election form if required by my state). Certain states do not require mandatory State Income Tax withholding but allow to elect State Income Tax withholding depending on the reason and type of withdrawal I have selected. I would like State Income Tax withheld - Optional State Income Tax withholding: % or $ (If this optional income tax election is permitted. I also have attached the proper income tax election form if required by my state to elect this optional withholding). H Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.) My Consent (Please sign on the My Signature line below.) I acknowledge that I have read, understand and agree to all pages of this Separation from Employment Withdrawal Request, the Participant Withdrawal Guide and the 402(f) Notice of Special Tax Rules on Distributions and affirm that all information that I have provided is true and correct. I understand the following: Any election on this Withdrawal Request form is effective for 180 days. It is my responsibility to ensure that this election conforms with all applicable provisions of the Internal Revenue Code (the "Code") and, if applicable, that the Plan into which I am rolling money over will accept the dollars. I am liable for any income tax and/or penalties assessed by the IRS and/or state tax authorities for any election I have chosen. Once a payment has been processed, it cannot be changed or reversed. In the event that any section of this form is incomplete or inaccurate, Service Provider may not process the transaction requested on this form and may require a new form or that I provide additional or proper information before the transaction can be processed. Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund s prospectus or other disclosure documents. I will refer to the fund s prospectus and/or disclosure documents for more information. Under penalty of perjury, I certify that the Social Security Number (or Taxpayer Identification Number) shown in Section A is correct. I am a U.S. person if I marked U.S. citizen or U.S. resident alien box in Section A of this form. Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC website at: about/organizational-structure/offices/pages/office-of-foreign-assets-control.aspx. For at least 30 days after my receipt of the 402(f) Notice of Special Tax Rules on Distributions, I have the right to consider whether to consent to a withdrawal of the vested account balance or elect a direct rollover of any vested portion of the eligible rollover withdrawal. By signing this form less than 30 days after I received the 402(f) Notice of Special Tax Rules on Distributions, I affirmatively waive any unexpired portion of the 30 day period and affirmatively elect a withdrawal from the account pursuant to this Separation from Employment Withdrawal Request form. My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service Provider for a withdrawal quote at Page 5 of 16

6 Last Name First Name M.I. Social Security Number Number H Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.) My Consent (Please sign on the My Signature line below.) Any person who presents a false or fraudulent claim is subject to criminal and civil penalties. Before signing this form: I must sign this form in the presence of a Notary Public or my authorized Employer if my withdrawal request will include a change of address or check delivery to an alternate mailing address. The date that I sign this form must match the date of the Notary Public or Employer signature. My Signature Date (Required) A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay. My Change of Address/Alternate Address Notarization May also be witnessed by my authorized Employer in the below section. Permanent Address Change - I would like the address on my account to be updated with this address. If I am requesting a check, I understand that it will be mailed to this address. Mailing Address City/State/Zip Code Alternate Mailing Address - I would like my withdrawal check to be sent to the following alternate mailing address. I understand that this address will be used for this withdrawal only and cannot be used for Periodic Installment Payments. Alternate Mailing Address City/State/Zip Code For Residents of all states (except California), please have your notary complete the section below. Notice to California Notaries using the California Affidavit and Jurat Form the following items must be completed by the notary on the state notary form: the title of the form, the plan name, the plan number, the document date, and my name. The notary forms not containing this information will be rejected and it will delay this request. The date I sign this form in the My Consent section must match the date on which my signature is notarized or witnessed in this section. Statement of Notary State of ) )ss. County of ) NOTE: Notary seal must be visible. This request was subscribed and sworn (or affirmed) to before me on this day of, year, by (name of participant) proved to me on the basis of satisfactory evidence to be the person who appeared before me. SEAL Notary Public My commission expires / / My Employer Witnessing My Signature (Please sign on the Employer Signature line below.) Only necessary if Notary signature is NOT obtained where indicated above. If the participant request includes an alternate mailing address and the participant s signature is not notarized, I certify that this request was signed by the participant in my presence. The date that I sign this form must match the date the participant has signed. I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form. I Employer Signature Where should I send this form? After all signatures have been obtained, this form can be sent by Fax to: Empower Retirement OR Regular Mail to: Empower Retirement PO Box Denver, CO If a Loan Payoff check is included, please use an address in Section F. OR Date (Required) Express Mail to: Empower Retirement 8515 E. Orchard Road Greenwood Village, CO Core securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers. GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company. Empower Retirement refers to the products and services offered in the retirement markets by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: NY, NY; and their subsidiaries and affiliates. The trademarks, logos, service marks, and design elements used are owned by their respective owners and are used by permission. Page 6 of 16

7 The Separation from Employment Withdrawal Request Before completing the form, please note the following information: Participant Withdrawal Guide - 403(b) Plan I must be eligible to receive a withdrawal from my employer's Plan. All pages of the Separation from Employment Withdrawal Request form ("Withdrawal Form") must be returned excluding the Participant Withdrawal Guide and the 402(f) Notice of Special Tax Rules on Distributions. Neither this Guide nor this Withdrawal Form are intended to provide tax or legal advice. In the preparation of this Withdrawal Form, and where I deem appropriate, I will seek a consultation with my accountant and/or tax advisor. I must complete a separate Withdrawal Form for each account or plan number. If I am a Beneficiary, I need to complete and submit a Death Benefit Claim Request form rather than this Withdrawal Form. If I am an Alternate Payee, I need to complete and submit an Alternate Payee QDRO Distribution Request rather than this Withdrawal Form. Changes to My Request Any changes to this Withdrawal Form must be crossed-out and initialed. If I do not initial all changes, this Withdrawal Form may be returned to me for verification. Incomplete or Inaccurate Information In the event that any section of this Withdrawal Form is incomplete or inaccurate, Service Provider may not be able to process the transaction requested on this Withdrawal Form. I may be required to complete a new form or provide additional or proper information before the transaction will be processed. Section A: What is my personal information? All information in this section must be completed. Personal information will be kept confidential. If I am a Non-Resident Alien, refer to the How will my taxes be withheld? section of this Guide to obtain more information about attaching an IRS Form W-8BEN. Section B: What is my reason for this withdrawal? I must designate only one withdrawal reason in order for my request to be processed. If more than one withdrawal reason is elected, this Withdrawal Form may be returned to me for further clarification. Once Service Provider has processed a withdrawal, it cannot be returned. The following is a brief explanation of each of the withdrawal reasons and associated requirements listed on this Withdrawal Form. I have Separated from Employment/Retired I would check this box to request a withdrawal from my account due to my separation from employment/retirement from the employer/company sponsoring this Plan. I must indicate the date of separation from employment/retirement on the line provided. Required Minimum Distribution (Age 70½) I must be separated from employment to be able to select this option and I must enter the date that I separated from employment on the line provided. I would check this box if I am age 70½ or older and I want to take a one-time withdrawal of my required minimum amount. I will be responsible for calculating my required minimum amount every year and completing this Withdrawal Form to request payment. If I would prefer to have my required minimum amount automatically calculated and sent to me each year, I must request an Automated Minimum Distribution Request form. Once the Automated Minimum Distribution Request form is completed and received by Service Provider, I will receive my required amount without additional paperwork. Section C: What type of withdrawal and how much am I requesting? I must designate a type of withdrawal in order for my request to be processed. Once Service Provider has processed a withdrawal, it cannot be returned. Certain fees, charges (including contingent deferred sales charge) and/or limitations may apply. Unless the plan has directed otherwise, the withdrawal will be prorated against all available investment options and all available contribution sources. The following is a brief explanation of each type of withdrawal listed on this Withdrawal Form. I must indicate whether I would like the funds associated with Great-West SecureFoundation Guaranteed Lifetime Withdrawal Benefit ("GLWB") to be included or excluded with this withdrawal request. By electing to include these funds with all other assets withdrawn on this request, I may reduce my Benefit Base and may eliminate the associated guaranteed income benefit. The funds associated with GLWB are: Great-West SecureFoundation Balanced G For additional options to withdraw the funds associated with GLWB, I should refer to and complete the GLWB Distribution/Direct Rollover Request form for instructions specific to these funds. For more information regarding GLWB, I should visit to view the Summary Disclosure Statement or speak to a representative at My Self-Directed Brokerage ("SDB") Account If I would like to receive a withdrawal from my SDB assets, it is my responsibility to contact the SDB provider directly to liquidate the securities and transfer the cash to the core investments (non-sdb investments) before my withdrawal request can be processed. Once the cash is swept into the SDB money market fund, I must request a transfer of the cash back to my Plan s core investment options by visiting or by calling If my Plan has a "core minimum" (the amount of investment funds, required by my Plan, that must be maintained in my core investment options at all times), and the transfer of funds has not been received by Service Provider prior to receipt of this Withdrawal Form, my request will be processed from the amount that is available in the core investment options in excess of the core minimum. For any further withdrawals, I must transfer the appropriate funds into my core investment options and submit an additional Withdrawal Form. Payable to Me as a One-time Withdrawal I would check this box to have my withdrawal made payable to me and enter the requested amount. Page 7 of 16

8 If I select the Net Amount box, the actual withdrawal amount will be greater than the withdrawal amount received to account for applicable income taxes and fees. If I select the Gross Amount box, applicable income taxes and fees will be withheld from the gross amount, resulting in an amount less than the requested amount. If both or neither check box is marked, the request will be processed as a Gross Amount. If I am electing a partial withdrawal, I must indicate the percent or amount in the lines provided. If I am electing this option for my Required Minimum Distribution, I must enter a dollar amount. Percentages are unavailable. If I am taking a withdrawal from a specific contribution source, I would enter it on the line provided. If I do not enter a contribution source, my withdrawal will be prorated against all of my available investment options and all available contribution sources. 100% Withdrawal With A Portion Payable to Me and the Remaining Balance as a Direct Rollover I would enter the requested amount to be paid to me and the remaining balance will be withdrawn as a direct rollover. If I select the Net Amount box, the actual withdrawal amount will be greater than the withdrawal amount received to account for applicable income taxes and fees. If I select the Gross Amount box, applicable income taxes and fees will be withheld from the gross amount, resulting in an amount less than the requested amount. If both or neither check box is marked, the request will be processed as a Gross Amount. I must indicate an Empower Retirement IRA or Empower Brokerage IRA, an IRA at another provider or specify an eligible Plan to accept the remaining assets that are rolled over. An eligible rollover withdrawal may be paid directly to Roth IRA. Mandatory Federal and State Income Tax withholding does not apply to this type of rollover. However, this withdrawal is subject to Federal and State Income Tax withholding and I am responsible for making tax payments. The taxable withdrawal will be reported on IRS Form 1099-R. Making an estimated tax payment to the IRS and an appropriate state authority at the time of this rollover may be one of the options to cover this tax liability. Where I deem appropriate, I will seek a consultation with my tax advisor. If I elect to rollover into an Empower Brokerage IRA, I must enter the account number(s) on the line(s) provided. The rollover may not be completed if the acceptance letter and the form provide conflicting information. I may be contacted to provide additional information. Required Minimum Distributions are not eligible for rollover. Rollover to an Empower Retirement IRA as a One-time Withdrawal I would check this box to have my withdrawal sent to an Empower Retirement IRA and elect whether the withdrawal will be going into a Traditional IRA or a Roth IRA. I must indicate the amount or percent of a partial withdrawal in the lines provided. The withdrawal will be prorated against all of my available investment options and all available contribution sources. An eligible rollover withdrawal may be paid directly to an Empower Retirement Roth IRA. Mandatory Federal and State Income Tax withholding does not apply to this type of rollover. However, this withdrawal is subject to Federal and State Income Tax withholding and I am responsible for making tax payments. The taxable withdrawal will be reported on IRS Form 1099-R. Making an estimated tax payment to the IRS and an appropriate state authority at the time of this rollover may be one of the options to cover this tax liability. Where I deem appropriate, I will seek a consultation with my tax advisor. The rollover may not be completed if the acceptance letter and the form provide conflicting information. I may be contacted to provide additional information. I must complete the Required Minimum Distribution information if I am age 70½ or older and I am requesting a 100% withdrawal as a direct rollover unless I have already satisfied my required minimum distribution for the year. Required Minimum Distributions are not eligible for rollover. Rollover to an Empower Brokerage IRA as a One-time Withdrawal I would check this box to have my withdrawal sent to an Empower Brokerage IRA and elect whether the withdrawal will be going into a Traditional Brokerage IRA or a Roth Brokerage IRA. I must indicate the amount or percent of a partial withdrawal in the lines provided. I must enter the account number for my Empower Brokerage IRA account(s) on the line(s) provided. The withdrawal will be prorated against all of my available investment options and all available contribution sources. An eligible rollover withdrawal may be paid directly to an Empower Brokerage Roth IRA. Mandatory Federal and State Income Tax withholding does not apply to this type of rollover. However, this withdrawal is subject to Federal and State Income Tax withholding and I am responsible for making tax payments. The taxable withdrawal will be reported on IRS Form 1099-R. Making an estimated tax payment to the IRS and an appropriate state authority at the time of this rollover may be one of the options to cover this tax liability. Where I deem appropriate, I will seek a consultation with my tax advisor. The rollover may not be completed if the acceptance letter and the form provide conflicting information. I may be contacted to provide additional information. I must complete the Required Minimum Distribution information if I am age 70½ or older and I am requesting a 100% withdrawal as a direct rollover unless I have already satisfied my required minimum distribution for the year. Required Minimum Distributions are not eligible for rollover. Rollover to an IRA at Another Retirement Provider or an Eligible Retirement Plan as a One-time Withdrawal It is my responsibility to determine if the IRA or an eligible retirement plan accepts eligible rollover withdrawals. I would check this box to have my withdrawal sent to an IRA or an eligible retirement plan at Another Retirement Provider or New Employer s Plan and enter the requested amount. The withdrawal will be prorated against all of my available investment options and all available contribution sources as allowed by IRS regulations. An eligible rollover withdrawal may be paid directly to a Roth IRA. Mandatory Federal and State Income Tax withholding does not apply to this type of rollover. However, this withdrawal is subject to Federal and State Income Tax withholding and I am responsible for making tax payments. The taxable withdrawal will be reported on IRS Form 1099-R. Making an estimated tax payment to the IRS and an appropriate state authority at the time of this rollover may be one of the options to cover this tax liability. Where I deem appropriate, I will seek a consultation with my tax advisor. It is my responsibility to make sure that the eligible retirement plan provides for a designated Roth account and can accept Roth rollovers. The rollover may not be completed if the acceptance letter and the form provide conflicting information. I may be contacted to provide additional information. I must complete the Required Minimum Distribution information if I am age 70½ or older and I am requesting a 100% withdrawal as a direct rollover unless I have already satisfied my required minimum distribution for the year. Required Minimum Distributions are not eligible for rollover. Periodic Installment Payments If I am requesting to establish a new periodic installment payment, I would check the box before I am requesting to establish a new Periodic Installment Payment. I would then fill in the First Payment Processing Date, Frequency and Payment Type. See Periodic Installment Payment Options below for explanation of the options available. If I have an existing periodic installment payment and I would like to change the frequency or payment date, I would check the box before I am making a change to an existing Periodic Installment Payment. I would then fill in the information that I want changed. Page 8 of 16

9 If my request is to establish a new periodic installment payment but I would also like to take a one-time partial withdrawal, I would check the box before I am also requesting a one-time withdrawal... and enter the dollar amount or percentage on the line provided. I would then fill in the First Payment Processing Date, Frequency and Payment Type. See Periodic Installment Payment Options below for explanation of the options available. If I select the Net Amount box, the actual withdrawal amount will be greater than the withdrawal amount received to account for applicable income taxes and fees. If I select the Gross Amount box, applicable income taxes and fees will be withheld from the gross amount, resulting in an amount less than the requested amount. If both or neither check box is marked, the request will be processed as a Gross Amount. Periodic Installment Payment Options First Payment Processing Date I must select a First Payment Processing Date. The First Payment Processing Date is the date the funds will be withdrawn from my account. I may choose any day between the 1st and the 28th for my First Payment Processing Date. If my chosen date falls on a non-business day (weekend, holiday, etc.) then my payment will distribute on the next available business day. Allow 5-10 business days from the First Payment Processing Date to receive the withdrawal. Frequency I must select the frequency of my payment from the available options. Payment Type Amount Certain (Gross Amount Only) I would select this option if I wish to receive specific dollar amount payments on an installment basis. The payments will continue until my account balance is zero. The number of payments I receive will vary depending on the performance of my underlying investment options. Period Certain (Specific Number of Years) I would select this option if I wish to receive a set number of periodic installment payments. Payment amounts will depend on the account value, which may fluctuate depending upon my chosen investments performance, the number of years I elect to receive payments and the frequency chosen. The payment amount will be calculated by dividing my current vested account balance by the number of remaining payments and is recalculated each time a payment is distributed; therefore, the amount of each payment typically differs. For example, if the payout is to be annually for 4 years, the initial payout amount will be equal to ¼ of my account balance. The second payment will be of my balance. The third payment will be ½ and the final payment will be the remainder of the account balance, resulting in a zero account balance. Interest Only Payments This option is only available to me if I have at least one fixed investment option. My payment will vary depending on the type and performance of the fixed investment options. My payment will continue until I reach age 70½, at which point my periodic installment payment option will be automatically converted to my required minimum distribution and withdrawals will be made at the same frequency as my interest only payments. Fixed Annuity Purchase An annuity is a payment option that can guarantee a retirement income for a fixed period or life. I will receive payments on the systematic basis that I have elected. Payments made under a fixed annuity option will not change for as long as the annuity period continues. To request an annuity quote, review the annuity options that follow and call Service Provider at The insurance company issuing the annuity will make annuity payments and will deduct the applicable income tax withholding. Once an annuity option is selected, I may not select a different withdrawal method or change to another fixed annuity option. To select this method, the minimum annuity purchase amount is $2, and each payment must be at least $ I am responsible for ensuring that the fixed annuity option as elected meets the required minimum distribution, if applicable. Fixed Annuity Purchase Options Purchase Date The purchase date is the date the funds are withdrawn from my existing account and placed into a fixed annuity. The purchase date may vary depending on the underlying investment options. If the purchase date is not a business day, the purchase date will default to the next business day. The selected purchase date must be prior to the payment start date. The interest rate applied will be the annuity rate in effect on the actual purchase date. If a purchase date is not entered, the purchase date will automatically be the date a properly completed Withdrawal Form is received by Service Provider. The purchase date cannot be more than 180 days from the date I complete this Withdrawal Form. First Payment Processing Date The First Payment Processing Date is the date the funds will be distributed from my account. The first withdrawal may be delayed 5-10 business days as my annuity account is established. The First Payment Processing Date cannot be more than 90 days after the purchase date. I am responsible for ensuring that the fixed annuity option as elected meets the required minimum distribution, if applicable. Payment Type Income of an Amount Certain (Gross Amount Only) This option provides for annuity payments in the amount and frequency I specify. The insurance company issuing the annuity will determine the number of payments and the payment may not be received over a period greater than 20 years. If I die before my entire annuitized balance is distributed, my beneficiary will receive all remaining annuity payments, if any. Income for a Period Certain (Number of Years) This option provides for annuity payments over the period and frequency I specify. The insurance company issuing the annuity will determine the amount of the payments. If I die before my entire annuitized balance is distributed, my beneficiary will receive all remaining annuity payments, if any. Fixed Life Annuity with Guaranteed Period This option provides for monthly annuity payments for the guaranteed payment period I have chosen (5, 10, 15, or 20 years) or for my lifetime, whichever is longer. If I die before the expiration of my elected guaranteed period, my beneficiary will receive all remaining payments, if any. Page 9 of 16

10 I must attach a copy of my birth certificate or driver s license. Fixed Life Annuity - Life Only, No Death Benefit This option provides for monthly annuity payments for my lifetime. All benefits stop upon my death. I must attach a copy of my birth certificate or driver s license. Joint Life This option provides for monthly annuity payments for my lifetime. Upon my death, my surviving joint annuitant will receive a pre-elected percentage (50, 75, or 100) of the original payment amount for his or her lifetime. For example, if I elect a joint and 50% annuity, my surviving annuitant will continue to receive fixed monthly payments equaling one half of the amount received while we were both living. I must attach a copy of both annuitants birth certificates or drivers licenses. Joint Life Annuity with Guaranteed Period This option provides for periodic annuity payments for the longer of the guaranteed period of mine or my joint annuitant's lifetime. If my death occurs prior to the expiration of the guaranteed period, my surviving joint annuitant will receive 100% of the original payment amount for the remainder of the guaranteed period. Upon expiration of the guaranteed period, my surviving joint annuitant will receive a percentage (that I elect on this form) of the original payment amount for his or her lifetime. For example, if I elect a joint and 50% survivor annuity with 10 years guaranteed, and my death occurs within 10 years of the first payment date, my surviving annuitant will receive 100% of the fixed payments for the remainder of 10 years, the original guaranteed period, then will receive payments equaling one half of the amount received while we were both living for the remainder of the surviving annuitant's life. If my death occurs after the guaranteed period, my surviving joint annuitant will receive a percentage of the original payment amount for his or her lifetime. For example, if I elect a joint and 50% survivor annuity with 10 years guaranteed, and my death occurs after 10 years from the first payment date, my surviving joint annuitant will receive payments equaling one half of the amount received while we were both living for the remainder of the surviving annuitant's life. If my joint annuitant dies before me, I will continue to receive 100% of the fixed payments for the remainder of my life. All payments will discontinue upon my death. I must attach a copy of both annuitants' birth certificates or drivers' licenses. Section D: To whom do I want my withdrawal payable and where should it be sent? It is my responsibility to make sure that the Trustee/Custodian/Provider information provided is accurate. Service Provider is not responsible for misdirected payments due to incorrect information or address. Section E: How do I want my withdrawal delivered? Certain delivery options are not available on all types of withdrawals. Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order. I must select a delivery option from the choices provided. If I do not make any selection, all transactions will be sent by United States Postal Service ( USPS ) regular mail. Below is a description of each delivery option. Check by USPS Regular Mail Estimated delivery time is 7-10 business days No additional charge If the check is payable to me, it will be sent to the address on file unless an address change or alternate address is indicated in the 'Signatures and Consent' section of the form and is properly notarized or witnessed. If the check is payable to another retirement provider, it will be sent to the address indicated in Section D. Check by Express Delivery Estimated delivery time is 1-2 business days A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction. For example, if I elected to make a full withdrawal with a portion payable to me and the remainder rolled over to an eligible plan, there will be 2 different transactions and I may be charged up to a total of $50.00 for the Express delivery fees. Not available for Periodic Installment/Annuity Payments Available for delivery, Monday-Friday, with no signature required upon delivery If the check is payable to me, it will be sent to the address on file unless an address change or alternate address is indicated in the 'Signatures and Consent' section and is properly notarized or witnessed. If the check is payable to another retirement provider, it will be sent to the address indicated in Section D. If the address is a P.O. Box, the check will be sent by USPS Express mail and estimated delivery time is 2-3 business days. Delivery is not guaranteed to all areas Direct Deposit via Automated Clearing House ("ACH") I would elect this option if I want my payment to be electronically deposited into my personal checking or savings account. Estimated delivery time is 2-3 business days A non-refundable charge of up to $15.00 will be deducted, in addition to any withdrawal fees, for each transaction. Not available for Direct Rollovers Available for Periodic Installment/Annuity Payments at no charge If I have requested a periodic installment payment and my first payment processing date does not allow for the 10 day pre-notification process, I understand that my first payment will be sent by check to my address on file. The name on my checking/savings account MUST match the name on file with Service Provider. For deposit into my checking account, I MUST attach a copy of a preprinted voided check for the receiving account. I may also attach a letter on financial institution letterhead, signed by a representative from the receiving institution, which indicates my name, checking account number and the ABA routing number. For deposit into my savings account, I MUST attach a letter on financial institution letterhead, signed by a representative from the receiving institution, which indicates my name, savings account number and the ABA routing number. An ACH request can not be sent to a prepaid debit card, an IRA, or a business account. Any missing, incomplete, or inaccurate information will delay my withdrawal request. Page 10 of 16